Wednesday, February 28, 2018

The Luxury to Choose

The 82-year-old woman lay on her mat, her legs powerless, looking up at the small group that had come to visit her. There were no more treatment options left. The oral liquid morphine we had brought in the small plastic bottle had blunted her pain. Nonetheless, she would be dead in the coming days. The cervical cancer that was slowly taking her life is a notoriously horrible disease if left undetected and untreated, and that is exactly what had happened in this case.

We had traveled hours by van along dirt roads to this village with a team of health workers from Hospice Africa Uganda, the country’s authority on end-of-life care, to visit the woman. She was the second patient of a similar condition I would see that afternoon.

Photo of Mbale, Uganda. Photo credit: Travis Bias, DO.

Back home, seeing an 80-year-old woman with advanced cervical cancer, let alone two in the same day, was exceedingly rare. In high-income countries, cervical cancer is a largely treatable disease, especially when caught in the early stages. And it is now preventable thanks to Gardasil, a widely accessible vaccine against Human Papillomavirus (HPV), the infectious agent that causes most cervical cancers. Physicians and other health care experts recommend the vaccine for all pre-teens in the United States.

“If only she had had access to Gardasil,” I thought to myself.

Just months earlier I was busy in my private primary care practice in Austin, Texas. In one of the richest countries on the planet that spends more on health care per person than anywhere in the world, I was putting forth my best effort to explain to a mother why her 14-year-old daughter, who had never before had any sexual contact, needed the series of three shots against HPV. “So this HPV is sexually-transmitted, and she still needs the vaccine even though she is not sexually active? And she does not need this shot to attend school?” Gardasil was a difficult sell in the conservative state that was careful about adopting what government, or anyone for that matter, recommended an individual do for the sake of public health.

It is now February 2018 and news reports are sounding the alarm about the strain of influenza making its way around the U.S., causing remarkably high rates of hospitalization and death. This disease can be easily prevented by one vaccine each flu season, yet patients decline this vaccine due to any number of excuses. “Won’t I be sick or sore for several days after?” “I am very careful about what I put in my body.” And the online “anti-vax” echo chamber encourages this behavior, turning one anecdote of a less-than-desirable reaction into several stories of harm attributed directly to a single shot in the arm.

What a luxury to choose from a menu of technological advances to protect one’s health. What a luxury to have an employer or taxpayer fund these ubiquitous means of preventing disease; whether it is a vaccine, a blood test, or a basic treatment. High-income societies have at times taken for granted life-saving resources. All to the detriment of their communities. What a luxury.

Considering the Centers for Disease Control and Prevention’s list of the top ten greatest public health feats of the last 100 years, we are on an incredible backslide to the year 1899. Measles was declared eliminated from the United States in 2000 thanks to widespread immunization, yet we now have outbreaks at Disneyland and anticipated future outbreaks due in part to conscientious objectors to the vaccine. Thanks to advancements in water treatment we no longer have major outbreaks of diarrheal disease, yet we now have entrepreneurs selling “raw water.”

What a luxury.

It is a cruel reality of inequality and resource mismatch across the globe when those without resources are clamoring for them, while those with resources refuse. Whether based on religious or individuality protests in conservative communities or “natural” ways of life in more liberal communities, the result is the same ignorance of science and reason. What a luxury.

But a heavily and densely populated globe interconnected by the increasing ease of international travel means that one person’s declined influenza vaccine might mean another person’s influenza death. The case of Ebola virus disease transported from Liberia to Dallas, Texas in 2014 highlighted how quickly and easily infectious diseases can spread across borders.

In a world of finite resources (yes, even in America) when does the conversation about personal responsibility turn to demand that individuals implement what is available to him or her to benefit their global community?

In a decade as a family medicine physician in the U.S., I had never before seen a death due to cervical cancer. With our suite of widely used screenings, diagnostic technology, and range of surgical solutions, cervical cancer-related deaths are exceedingly rare. And now that we have deployed the vaccine, Gardasil, cervical cancer rates worldwide have been cut in half.

“If only this woman had had access to Gardasil,” I thought to myself. Instead, the 82-year-old matriarch tried to maintain her dignity in the face of a spreading cervical cancer, urinating on a plastic tarp in her niece’s concrete open-air house and controlling her pain with ibuprofen and oral liquid morphine. If only she had had access to that luxury to prevent her cancer. With a little public will, perhaps her great-granddaughters — and mine — will.Travis Bias, DO, is a family medicine physician who once practiced in Texas and now practices in California. He also is a medical and public health educator. Dr. Bias was an active member of the Texas Medical Association while in the Lone Star State. Connect with him at his blog, The Global Table, or on twitter @Gaujot.

1 comment
:

Life expectancy in Uganda is 59.3, and life expectancy in the United States is 78. If only this Ugandan matriarch had Gardasil she could have lived to 97? I struggle to find a coherent message in this article but I will try. Americans live in healthcare luxury but make bad decisions about their healthcare because they are spoiled and should be more responsible but also everyone should get their vaccinations because influenza is deadly (despite limited vaccine effectiveness this season), and ebola spreads fast. Ugandan octogenarians are dying from cervical cancer while they could or should be dying from something else. If Americans aren't more responsible, society should force healthcare decisions upon them. What a luxury.

Dr. Bias perhaps should spend more time in impoverished underserved areas in this country and realize that there is an exceptional amount of preventable disease burden much closer to home.

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